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            I, ___________(1)___________, of __________(2)_________, hereby appoint ______________(3)________________ of ___________(4)_______________, as my attorney in fact to act in my capacity to do any and all of the following:

            1. Make any and all decisions and authorize all procedures that _____(5)____ may deem necessary regarding the medical treatment of my children, _____(6)_____ and/or ______(7)______.

            The rights, powers, and authority of my attorney in fact to exercise any and all of the rights and powers herein granted shall commence and be in full force and effect and shall remain in full force and effect until ___________(8)_______________ or unless specifically extended or rescinded earlier by either party.

            Dated ___________(9)______________, 19_(10)_.


            STATE OF _______(12)____________

            COUNTY OF ______(13)____________

            BEFORE ME, the undersigned authority, on this _(14)_ day of _______(15)________, 19_(16)_, personally appeared ___________(17)___________ to me well known to be the person described in and who signed the Foregoing, and acknowledged to me that he executed the same freely and voluntarily for the uses and purposes therein expressed.

            WITNESS my hand and official seal the date aforesaid.


                                                 NOTARY PUBLIC

                                 My Commission Expires:__(19)___


            The information in this document is designed to provide an outline that you can follow when formulating business or personal plans.  Due to the variances of many local, city, county and state laws, we recommend that you seek professional legal counseling before entering into any contract or agreement.

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